SAMHSA Must Be Headed by a Psychiatrist

In January Elinore McCance-Katz, M.D., Ph.D., resigned after almost four years as director of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the first assistant secretary for mental health and substance use in the Department of Health and Human Services. She was also the first psychiatrist to direct the 29-year-old agency, which is surprising given SAMHSA’s mandate to “reduce the impact of substance abuse and mental illness on America’s communities.” In fact, very few psychiatrists have been employed by SAMHSA in any capacity among its 500-plus employees. For long periods only a single psychiatrist was employed, and for at least one shorter period there was no psychiatrist at all.

Dr. McCance-Katz, the former chief medical officer in the Rhode Island Department of Behavioral Healthcare, had clinical experience in mental illness, including substance use disorders. At SAMHSA, she focused on both areas. She made a special effort to rebalance the agency`s priorities as individuals with severe psychiatric disorders had been too often neglected. She helped increase the availability of psychiatric beds by securing Medicaid waiver authority to allow states to modify the Institutions for Mental Disease (IMD) exclusion. The exclusion had disallowed Medicaid payments for patients between the ages of 21 and 64 living in facilities with more than 16 beds that primarily provided mental health care. She also changed federal guidelines to permit Mental Health Block Grant funds to be used for mental health services for mentally ill individuals who are incarcerated, as long as the services are provided by community-based providers.

Dr. McCance-Katz also funded 37 Assisted Outpatient Treatment (AOT) demonstration programs. AOT is especially useful for individuals with serious mental illnesses who are unaware of their own illness. Evaluation data have shown that such programs dramatically decrease psychiatric hospitalizations, emergency room visits, incarcerations, and homelessness among this very disabled population. To further improve psychiatric outpatient treatment, she also increased funding for Certified Community Behavioral Health Clinics from $100 million to $450 million and required the clinics to provide crisis services 24/7 as an alternative to costly emergency room visits.

Aware that the last major study of the prevalence of serious mental illness was funded by the National Institute of Mental Health in the early 1980s, Dr. McCance-Katz sought to generate recent data by investing $30 million to initiate a major prevalence study on mental disorders and substance use, focusing especially on individuals who are incarcerated or homeless. Finally, on December 17, 2019, she helped organize a high-profile White House Conference on serious mental illnesses with the president in attendance. This was the first White House meeting ever to focus on this population.

The last four years at SAMHSA have thus demonstrated the importance of having a psychiatrist in the lead federal role to oversee psychiatric services. Most SAMHSA directors not trained in psychiatry have tended to minimize or to ignore altogether the needs of the most seriously mentally ill people. In recent years the mental health field has tended to promote to leadership positions individuals who have had a “lived experience.” Such perspectives can be very helpful in designing certain kinds of services. But the scope of SAMHSA’s responsibility to the nation is too wide and complex to be steered by a director whose ideas about mental illness are primarily rooted in personal experience.

We hope that President Biden and HHS nominee Xavier Becerra are aware of the progress made in the last four years and the need to continue this progress. Recognizing the importance of federal psychiatric leadership will increase the chances of that happening. ■